A Rare Care of Subcutaneous Emphysema After Colonoscopy with No Identifiable Mucosal Defect

Abstract

We present an interesting case of subcutaneous emphysema after colonoscopy with near-obstructing mass noted at the hepatic flexure in an overall healthy 91-year-old female. Our patient was a healthy 91-year-old woman who presented with one week of right lower abdominal pain that started after a fall. CT scan of the abdomen revealed an indeterminate lesion at the cecum. A colonoscopy was performed for further evaluation and demonstrated a near obstructing lesion at the hepatic flexure that could not be traversed with the colonoscope. Biopsies were taken and the area was tattooed. After outpatient discharge following the colonoscopy, the patient re-presented to the emergency room with complaint of abdominal distention. While in the hospital she developed subcutaneous crepitus in the neck and face. Subsequent imaging revealed a large amount of subcutaneous air and findings consistent with pneumoperitoneum. She was hemodynamically stable, however given the concern for possible perforated viscus post-colonoscopy, the patient was urgently taken the operating room for an exploratory laparotomy and right-sided hemicolectomy. During surgery no full thickness tear of the colon was visualized. No defect was identified in colonic mucosa by pathology. It was only notable for adenocarcinoma. Subcutaneous face and neck emphysema is a rare complication after colonoscopy. The vast majority of cases of subcutaneous emphysema following colonoscopy in the literature are postulated to be secondary to colonic perforation and have been managed successfully with nonoperative treatment. Our case is unique in that our patient was taken to the operating room due to the obstructive lesion found, yet thorough examination of the colon intraoperatively and by pathology demonstrated no frank evidence of colonic perforation. Another interesting part of the case is the use of India ink tattooing of the obstructing lesion during the index colonoscopy to mark the lesion, which has also rarely been reported in the literature as a cause of occult perforation. Finally, the patient in our case could have been presenting with benign pneumoperitoneum found incidentally on imaging that were unrelated to her complaints of abdominal distension. While also uncommon in the literature, authors have recommended treating all cases of potentially benign pneumoperitoneum as perforations nonetheless, a practice that was followed in this patient's care. The patient recovered uneventfully.1576_A Figure 1. Stricture at hepatic flexure noted during colonoscopy1576_B Figure 2. Right eye crepitus1576_C Figure 3. Gross specimen